Many Patients Don't Pursue Referrals

FRIDAY Aug. 3, 2007 -- About 20 percent of patients don't follow up on their doctor's referrals to specialists, new research shows.

"For a long time, physicians have been concerned recommendations to see a specialist may not be carried out," noted lead researcher Dr. Christopher B. Forrest, from the department of pediatrics at Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine.

More patients would follow through with a referral if they had more discussion with their primary care doctor, Forrest believes. "Patients should probe their physician to find out why the specialist visit is necessary, what the expected outcomes would be, [these] are all elements to negotiate before the referral even happens," he said.

In the study, Forrest's team collected data on 776 patients cared for by 133 doctors in 30 states.

Among the 132 patients who did not see a specialist, 47.5 percent said the medical situation had resolved itself; 37.3 percent said they didn't have the time, and 26.5 percent said they had disagreed with their doctor's advice, according to the report in the July/August issue of the Annals of Family Medicine.

Patients who asked their doctor for a referral were more likely to follow through, Forrest noted. In fact, 92.4 percent of those who requested a referral saw a specialist, compared with 81.9 percent of the patients whose doctor suggested the referral.

Another aspect that influenced whether or not a patient was likely to see a specialist was their relationship with their primary care doctor.

"Having a long-term relationship seemed to make a difference," Forrest said. "It makes a difference whether you have a strong relationship with your primary care doctor or a weaker relationship," he said. "That is an important factor in trusting the recommendation of the doctor."

According to Forrest, patients are more likely to go to a specialist if their primary care doctor makes the appointment. "Patients who left the office with an appointment were more likely to attend," he said.

In addition, insurance coverage was also a factor in whether or not patients saw a specialist. Patients on Medicaid were less likely to follow through on the referral and more likely to be denied coverage by their health plan, the study found.

"And patients who did not have health insurance were less likely to be referred at all," Forrest said. "If they were referred, they had more difficulty finding a specialist who would give them an appointment," he said.

One expert applauded the study.

"The study takes something that is anecdotally known to all physicians and converts it into data," said Dr. Albert Wu, a professor of health policy and management at Johns Hopkins University Bloomberg School of Public Health in Baltimore.

Wu was actually impressed by the results, pointing to the fact that 80 percent of patients do appear to keep their referral appointments. "I'm not sure that the completion rates for my patients is that high," he said. "I suspect these results are optimistic."

He agreed that communication between doctor and patient is key to the referral process. "More discussion about referrals would be helpful," he said.

Patients may not assign a sufficient priority to the visit, Wu said. "And a lot of people have aversion to procedures," he said. "Simply assuming that once the referral is written it is going to happen is a bit Pollyannaish."